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PubMed2003

Instability following total hip arthroplasty.

Dislocation is the second most common complication of total hip arthroplasty. Most dislocations occur early in the postoperative period and are caused by patient factors, surgical factors, or a combination of both. Patient factors that predispose to postoperative dislocation include previous surgery and neurologic impairment. Surgical factors include surgical approach, component orientation, and prosthetic and/or bony impingement. Evaluation of patients undergoing total hip arthroplasty requires a thorough history and physical examination, as well as a detailed radiographic assessment. Closed treatment of instability is successful in two thirds of cases; the remainder require surgical management. Surgical techniques used to treat or minimize risk of further dislocation include revision arthroplasty, trochanteric advancement, use of elevated rim liners, and use of constrained liners.

Arthroplasty, Replacement, Hip↗
PubMed1992

The management of fixed flexion contractures during total knee arthroplasty.

Fifty-one knees in 40 patients with joint surface degeneration accompanied by fixed flexion contractures (FFC) greater than 20 degrees were treated with total knee arthroplasty using a minimally constrained posterior cruciate ligament retaining prosthesis. Special techniques were employed in an attempt to achieve maximal correction at the time of surgery. The residual FFC measured 3.1 degrees at the completion of the arthroplasty, 10.1 degrees at three months, and 7 degrees at two years. At 55 months postoperatively, the FFC for the osteoarthrotic group had improved from 25.5 degrees to 3.6 degrees, whereas the rheumatoid group improved from 28.7 degrees to 8.6 degrees. The average knee score for the osteoarthrotic group was 89 compared with 81 for the rheumatoid group. Knees that were left with greater residual FFC at the completion of the arthroplasty were found to have greater residual FFC at the latest review.

Adult↗
PubMed2003

Implementation of a CT-based navigation system in two-stage reimplantation for infected total knee arthroplasty.

Femorotibial alignment is an important factor affecting patient outcome after total knee arthroplasty (TKA). It was the aim of this study to report our first results using a CT-based navigation system in two-stage revision surgery for infected TKA. Two patients with chronic deep infection after primary TKA underwent two-stage revision arthroplasty with temporary articulating cement spacers followed by prosthesis re-implantation using a CT-based navigation system. Postoperative radiographs showed accurate alignment of the femoral and tibial components. CT-based navigation systems offer the opportunity for preoperative planning and accurate intra-operative navigation of cutting blocks. They can be considered of value for primary TKA but even more so for two-stage revision arthroplasty.

Aged↗
PubMed2003

Clinical biomechanics of wear in total hip arthroplasty.

Complementary clinical and laboratory studies were performed to identify variables associated with polyethylene wear following total hip replacement, and to elucidate the mechanisms responsible for accelerated wear in the total hip arthroplasty construct. Observational cohort studies were performed using a prospective clinical database of more than 4000 consecutive primary total hip arthroplasties performed by a single surgeon, to identify wear-related variables. These variables included head size, acetabular/femoral component impingement, and third body debris. Novel digital edge detection techniques were developed and employed to accurately measure wear, and to determine the relationships of head size and third body debris to acceleration of wear. A novel sliding-distance-coupled finite element model was formulated and employed to examine the mechanisms responsible for wear. The long-term cohort studies demonstrated smaller head sizes to be associated with less wear. Third body debris generated from cable fretting was associated with an increase in wear, osteolysis, and acetabular loosening, especially with larger head sizes. The sliding-distance-coupled finite element model replicated the wear rates occurring in vitro and in vivo, demonstrating the importance of sliding distance on polyethylene wear following total hip arthroplasty. It also demonstrated substantial increases in wear associated with femoral head scratching from third body debris. Further extension of the finite element formulation demonstrated the potential for acetabular component rim damage from impingement wear, and the enhanced potential for third body ingress to the bearing surface with larger head sizes. Edge detection wear measurement techniques demonstrated that early wear rates were predictive of long-term wear rates. These complementary clinical and laboratory investigations have provided insight into 1) the significance of sliding distance and physiologic loci of motion as contributing factors in minimizing wear, 2) the deleterious effects of third body particulates in accelerating wear, 3) the potential for, and factors related to, impingement wear, and 4) the potential advantages and compromises related to the use of larger head sizes in the bearing surface construct.

Arthroplasty, Replacement, Hip↗
PubMed2003

Early postoperative mortality following total hip arthroplasty in a community setting: a single surgeon experience.

The senior author performed 4967 total hip arthroplasties, 4164 primary and 803 revision, between 1970 and 1996 in a community setting. All charts were evaluated for postoperative death including in-house, 30, 60, and 90 days following the procedure. 1.0 per cent of patients (42) died following a primary procedure and 0.87 per cent (7) died following a revision procedure within 3 months of surgery. The number of in-house deaths were 26 (0.52 per cent), including 21 in the primary group (0.5 per cent) and 5 in the revision group (0.62 per cent). In both the primary and revision situation and independent of co-morbidities, age greater than 70 years was significantly associated with increased risk for post-operative mortality (p<0.0001), with 0.44% mortality in patients aged 70 years or younger (0.51 per cent primary and 0.00 per cent revision), and 1.45 per cent mortality in patients greater than 70 years of age (1.38 per cent primary and 1.86 per cent revision). This experience of a single surgeon with a high volume community practice performing both primary and revision total hip arthroplasty, documents a low but significant incidence of postoperative death in the first 3 months following total hip arthroplasty (0.98 per cent).

Aged↗
PubMed2003

Unicompartmental knee arthroplasty: is it durable?

AIM: To analyse the long-term durability of unicompartmental knee arthroplasties using the Marmor/Mod 2 prosthetic. METHODS: Survivorship analysis was used to retrospectively evaluate 113 medial unicompartmental knee arthroplasties performed between 1974 and 1989 in two New Plymouth hospitals. An outcome was determined for every case. RESULTS: The survival rate was 95% at 10 years and 85% at 15 years. All 27 knees surviving at the time of the study were assessed clinically using the Knee Society Score, and 25 of the 27 knees underwent radiographic evaluation. The Knee Society Knee and Knee Society Functional scores were 72 points and 56 points respectively for the group of 27 surviving prostheses, and the 25 knees X-rayed showed no loosening or fracture of the prosthesis. CONCLUSIONS: Unicompartmental knee arthroplasty with the Marmor/Mod 2 prosthesis has provided satisfactory long-term durability in this cohort of elderly patients, in comparison with similar published studies featuring other prostheses.

Adult↗
PubMed2003

Anthropometric measurements of the human knee: correlation to the sizing of current knee arthroplasty systems.

BACKGROUND: There is a paucity of data concerning the morphological dimensions of the distal part of the femur, the proximal part of the tibia, and the patella. The objective of this study was to analyze the exact anatomic data collected from a large group of patients undergoing total knee arthroplasty and to correlate the measurements to the dimensions of current prosthetic systems. METHODS: Eight different centers collected morphologic data from the distal part of the femur, the proximal part of the tibia, and the patella from 337 knees during total knee arthroplasty. Microcaliper measurements from templates and measuring guides were used to decrease intraobserver variation. The study included 188 women (209 knees) and 107 men (128 knees) who had a mean age of sixty-nine years. A characterization of the aspect ratio (the medial-lateral to anterior-posterior dimensions) was made for the proximal aspect of the tibia and the distal part of the femur. Known dimensions from six prosthetic knee systems were compared with the morphologic data. RESULTS: A wide variation in the aspect ratio for the femoral component was seen among the six different prosthetic systems. For women, there was a significant association between the component size and the amount of medial-lateral overhang, with larger sizes having more overhang (p < 0.0001). Although the femoral aspect ratio for the morphologic data showed higher ratios for smaller knees and proportionally lower ratios for larger knees, the designs showed little change in the aspect ratio. The tibial aspect ratio from the morphologic data showed a higher ratio for smaller knees and a proportionally lower ratio for larger knees. The Duracon component tracked the decline in aspect ratio fairly well, whereas the other brands either did not change with anterior-posterior dimension or actually increased (NexGen). Gender differences in the morphologic data were shown by the variable tibial aspect ratios. A comparison of the bone dimensions from the study data and the dimensions of the implants indicated that the smaller sizes were too small while the larger sizes tended to be too large. The average overall unresected patellar thickness was 23.7 mm. CONCLUSION: The results of this study will allow manufacturers to make more appropriate determinations of the sizes and aspect ratios of components for use in total knee arthroplasty.

Adult↗
PubMed2003

Management of the infected hip arthroplasty by two-stage reimplantation.

The aim of this study is to present our experience with two-stage reimplantation in the management of the infected hip arthroplasty. Between January 1993 and December 2001 the replacement of the total hip arthroplasty in two stages was performed in 18 patients. There were 7 male and 11 female patients and the average age was 62 years. The mean follow-up after revision was 3.5 years. The mean postoperative Harris Hip Score averaged 78 (50-96) points. None of 18 patients had a recurrence of the infection. Two-stage reconstruction of the infected hip is preferred to one-stage exchange arthroplasty at our department because of higher rate of eradication of the infection.

Aged↗
PubMed1992

[Interposition arthroplasty with pedicled island fascia flap. Experimental study and clinical application].

Interposition arthroplasty of knee joint, using island fascia flap, was performed on 90 rabbits. The fascia flap was vessel pedicled in 54 rabbits and not vessel pedicled in 36 for control. Results of the vessel pedicled island fascia flaps showed that clinically, the range of joint motion was 142.5 degrees on the average. Histologically, the transplanted fascia showed good vascularity and elasticity. There were no signs of adhesion or degeneration. Analogous cartilage appeared in 12 to 15 months. In the control group, the average joint motion was 83.61 degrees and the transplanted fascia showed degeneration of varying degree in each cases. On the basis of these experimental findings, we performed interposition arthroplasty with vessel-pedicled island fascia flap on 20 patients suffering from different joint diseases. The joints were 14 hips, 3 knees, and 3 elbows. Follow-up for 9 to 48 months after arthroplasty revealed clear-up of previous troubles with satisfactory function.

Adolescent↗
PubMed2004

Satisfactory results of Stanmore total hip arthroplasty after failed osteosynthesis of the femoral neck.

Treatment of fractures of the femoral neck by closed reduction and internal fixation results in a high incidence of complications, and often requires secondary total hip arthroplasty. We retrospectively studied 31 patients who underwent a Stanmore (Howmedica) total hip arthroplasty performed five months (median) after osteosynthesis. The most common indications were: failure of fixation (n = 14), osteonecrosis (n = 9) and secondary osteoarthritis (n = 6). Eight patients had a maximum follow-up of 12 months; the median follow-up was 30 months in the remaining group of 23 patients. Although one patient had radiographical signs of femoral loosening, none of the patients studied needed revision of the total hip arthroplasty. Using the Merle d'Aubigné scoring system, we found excellent results in 94% of the cases. Despite the short-term follow-up and the small number of patients, we conclude that the Stanmore THA was a satisfactory salvage procedure after failure of internal fixation for femoral neck fracture.

Aged↗
PubMed2004

Post impingement in posterior stabilised total knee arthroplasty.

Posterior stabilised implants are a well-proven treatment for patients requiring primary total knee arthroplasty. Concerns about the posterior stabilised (PS) design have been raised and recent studies suggest that the post-cam articulation can be an additional source of polyethylene wear debris. In this study, the authors report impingement of the tibial post against the patellar component in deep flexion in posterior stabilised total knee arthroplasty. Their data suggest that "post impingement" is associated with a raised joint line, patella infera, too anterior placement of the tibial component and a smaller femoral component size. "Post impingement" may lead to extensor mechanism problems and additional polyethylene wear and therefore may affect the longterm functional results of posterior stabilised total knee arthroplasty.

Aged↗
PubMed2004

[Evaluation of results after reimplantation of total hip arthroplasty cemented cup].

PURPOSE OF THE STUDY: The aim of the study is to evaluate the results achieved after the replacement of a loosened or broken cemented cup by another cemented cup and to specify conditions under which such procedure may be successful. MATERIAL: In the period of 1992-1997, 158 revision surgeries of total hip arthroplasty were performed at the authors' Department. In 69 patients (57 women, 12 men) the cemented cup was replaced by another cemented cup and the original femoral monocomponent with the 32 mm head diameter the surface of which was not damaged was left in place. METHODS: The indication for operation was loosening of Degree 2 or 3 of the classification after Krbec et al. The surgery was performed from the Watson-Jones or Bauer approach. The cup was always revised with the use of the Palacos cement in combination with antibiotics by the cementing technique of 2nd generation. Augmentation was used in 11 cups. The original femoral component was always returned to the original cemented bed and a cement mantle was added in the proximal part in 15 patients. Poldi cups were replaced in all patients of the followed up cohort (63 times loosening--91%, 6 times breakage--9%) using 3 types of cups for revision surgery (Poldi--44 times, Ultima--20 times, SPC--5 times). During the period of March through December 2001, 48 patients were followed up in the out-patient department. The clinical condition was evaluated on the basis of the Harris Hip Score and a radiograph was made to monitor changes in the position of the cup, linear wear, the presence and size of the radiolucent zone. RESULTS: The results were evaluated in 48 patients (40 women and 8 men) with the average interval of 63 months after revision of the cup (range, 46 to 112 months). However, the clinical and radiograph evaluation of the condition was made only in 45 patients. Three patients re-operated on in 2001 were not included in the evaluation. The Harris Hip Score was on average 78 points (range, 51 to 97 points). Radiographs did not show any change in the position of the cup. The linear wear up to 1 mm was revealed in 4 cups and above 1 mm in 1 cup (11% of the evaluated patients). The radiolucent line in zone III after DeLee and Charnley was present in 4 cups, in zones II and III in another 4 patients, i.e. in total in 8 of 45 cups (18%). DISCUSSION: The group of 45 followed-up patients may be considered a sufficiently representative sample of the original 69-member cohort (minimally 7 patients died in the follow-up period, 3 patients were not included in the evaluation). With regard to the average follow-up of 63 months the results may be considered as medium-term. The average interval between primary total hip arthroplasty and revision of 130 months is comparable with the results of similar studies by other authors. The results of the clinical evaluation on the basis of Harris Hip Score are not convincing (range, 51 to 97 points, average 78 points). Radiographs showed a radiolucent zone in 8 cups (18%). Another 3 patients were at the time of evaluation after a repeated revision of the cup for loosening (at the interval of 22 to 34 months). CONCLUSION: A good integration of the cemented cup used in revision of the loosened cemented cup of total hip arthroplasty was evident only in infrequent cases of a perfectly preserved acetabulum both from the viewpoint of shape and structure. The evaluation of other patients of the followed-up cohort, however, produced rather unconvincing results. On this basis and also on the basis of their experience in the use of cementless cups in revision of total hip prostheses the authors recommend to prefer a cementless implant in the revision of the cup.

Aged↗
PubMed2004

[Early results of total ankle arthroplasty].

UNLABELLED: Objective of the study was to evaluate total ankle arthroplasty as the treatment of choice for ankle arthritis; to analyze variables' influence upon early results after total ankle arthroplasty; and to determine early and late postoperative complications and the ways to avoid them. MATERIAL AND METHODS: We evaluated clinical results of 18 patients (out of 23 operated patients), for whom total ankle replacement was performed in 1998-2003. Uncemented Scandinavian Total Ankle Replacement (WLink, Germany) endoprosthesis was used in all cases. The patients were examined, questioned and evaluated according to modified rating system recommended by American Orthopedic Foot and Ankle Society. We observed early and late postoperative complications. RESULTS: Excellent and good results were observed in 9 cases (50%); fair results were in 6 cases (33%), poor in 2 cases (12%), and failure in 1 case (5%). Complications occurred in 11 cases (61%): 4 patients had neurological complaints in operated foot, delayed wound healing was observed in 2 cases, 3 patients had plantar flexion contracture, for 1 patient arthrodesis was done because of dislocation of meniscus component. CONCLUSIONS: Total ankle replacement is an alternative treatment to arthrodesis after posttraumatic ankle arthritis. Results after total ankle arthroplasty are worse than after total hip or knee replacement. Operative technique has great influence on total ankle replacement results. Accurately selected indications for surgery decrease complication rate.

Adult↗
PubMed2004

Glenoid resurfacing in shoulder arthroplasty: indications and contraindications.

The indications for glenoid resurfacing are controversial. Advantages of glenoid resurfacing include decreased glenoid pain from metal-on-bone articulation, increased stability provided by the conforming glenoid component in the presence of asymmetric glenoid wear, and lateralization of the joint line providing for improved range of motion and strength. Proponents of hemiarthroplasty claim that function and pain relief are equivalent to glenoid resurfacing without the concomitant risk of glenoid loosening and loss of glenoid bone stock. In addition, hemiarthroplasty requires less surgical time and is less expensive than total shoulder arthroplasty. Total shoulder arthroplasty has been shown to be superior to hemiarthroplasty with regard to pain relief, range of motion, and function. Resurfacing of the glenoid has been indicated in older patients with primary osteoarthritis. In addition, patients with rheumatoid arthritis generally have better improvement in pain and function when treated with total shoulder arthroplasty than with hemiarthroplasty. Patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock should be treated with hemiarthroplasty alone because glenoid resurfacing is associated with early loosening and failure. Patients with osteonecrosis isolated to the humeral head should be treated with hemiarthroplasty to preserve the native, congruent glenoid.

Arthritis↗
PubMed2004

Evaluation of the unstable total hip arthroplasty.

Despite advances in total hip arthroplasty, dislocation persists as a troublesome complication for orthopaedic surgeons to manage, second only to prosthetic loosening as a cause of revision. Although this complication has received considerable attention, evaluation and treatment of the unstable total hip arthroplasty remain poorly understood. Therefore, it is important to evaluate such factors as underlying patient comorbidities, the direction of dislocation, soft-tissue tension, surgical technique, implant design, and component position. For recurrent hip instability, a careful history to determine the mechanism of dislocation is necessary, and a review of preoperative imaging studies can help clarify whether gross component malpositioning is present. Examination under anesthesia and intraoperative inspection are also important. Taking the hip through a full range of motion while directly visualizing the anatomy can help diagnose component-to-component impingement, inadequate offset soft-tissue tension, extra-articular impingement, and other possible contributing factors. Even when a seemingly obvious cause of dislocation, such as component malposition, is diagnosed, surgical results have been somewhat disappointing. Therefore, surgical planning should include all possible revision options, and the temptation to find the quick fix should be resisted. Patients should be extensively counseled regarding realistic expectations both before primary hip arthroplasty and in the face of a revision surgery for recurrent dislocations because long-term results are less than optimal.

Arthroplasty, Replacement, Hip↗
PubMed2004

Sources of osteolysis around total knee arthroplasty: wear of the bearing surface.

Once mostly a problem in total hip arthroplasty, osteolysis has now emerged as a significant problem around total knee arthroplasty (TKA). The development of osteolysis is often related to wear of the polyethylene bearing surface with production of biologically active particulate debris. There are many structural and design factors related to the polyethylene bearing surface that have been shown to affect the extent of wear that occurs over time. For instance, the processing, manufacturing, and sterilization methods of polyethylene all are critical factors in determining its mechanical and wear-resistant properties. Cross-linking of polyethylene bearing surfaces in TKA, however, may not demonstrate the same degree of improved resistance to wear as seen in total hip arthroplasty. Optimization of polyethylene bearing surface thickness, with a goal to insert at least 8 mm of polyethylene, has been shown to minimize contact stresses and subsequent fatigue failure of total knee implants. Selecting a well-designed component with minimal counter surface roughness is also important in minimizing the generation of polyethylene wear debris and subsequent osteolysis. Finally, proper surgical technique, including restoration of mechanical axis and rotational alignment, is critical to minimizing wear and maximizing the longevity of TKA.

Arthroplasty, Replacement, Knee↗
PubMed2004

Primary exchange revision arthroplasty for infected total knee replacement: a long-term study.

Infected knee replacement is a serious complication that requires significant hospital-based resources for successful management. A successful primary exchange revision technique offers decreased morbidity for the patient by eliminating a second major operation and associated hospitalization, which in turn substantially reduces the cost associated with this dreaded condition. Twenty-two consecutive infected primary total knee arthroplasties in 22 patients were treated with primary exchange revision arthroplasties using antibiotic-impregnated cement. The surgical technique consisted of excision of draining sinuses, complete synovectomy, removal of granulation tissue, and debulking of the extensor mechanism. Postoperative treatment consisted of 4 to 6 weeks of parenterally administered antibiotics and 6 to 12 months of orally administered antibiotics. Both gram-positive and gram-negative organisms were treated. At an average follow-up of 10.2 years (range, 1.4 to 19.6 years), 90.9% were free of recurrent infection. Knee scores averaged 79.5, with 85.7% good or excellent results. The physiological classification of the host appeared to influence the outcome of revision. All patients in class A or B (20 knees) had successful eradication of their primary infection after 1-stage revision, whereas the only failure in the group was a physiological class C patient, who eventually expired from ongoing end-organ liver failure. These results compare most favorably with those of delayed-exchange revision arthroplasty while providing a more cost-effective management program.

Aged↗
PubMed2004

[Short-term results of modular extensively porous-coated revision stem in revision total hip arthroplasty].

OBJECTIVE: To evaluate the short-term clinical and radiographic results of modular fully porous-coated stem in revision operation of total hip arthroplasty. METHODS: From May 2001 to November 2002, ten cases with twelve hips received revision total hip arthroplasty using modular Profemur R with fully porous-coated stem. There were three males and seven females and the average age was 54.2 years (35 to approximately 71 years). The reasons for revision operation included aseptic loosing in eleven hips and septic loosing in one hip. All the patients were evaluated radiographically and clinically. Radiographic evaluation included the classification of bone loss, leg discrepancy, offset and antiversion before and after revision and bone in-growth postoperatively. Clinical evaluation were based on Harris score system. RESULTS: The average follow-up period is 13.5 months (range: 6 to approximately 24 months). Leg discrepancy from more than 2 cm in six cases were restored to less than 1 cm postoperatively. Femoral offset, antiversion angle and neck-shaft angle were also restored to normal limitation. All the patients were allowed to full weight-bearing 3 to approximately 5 months later and pain relief occurred in all involved hips. At the last follow-up, bone in-growth occurred in eleven hips and solid fibrous fixation only in one case. Harris score was improved from a mean of 25 to 72. Complications mainly consisted of femoral shaft fracture in three cases but no infection or dislocation was found postoperatively. CONCLUSIONS: Satisfactory results of short-term radiographic and clinical follow-up can be achieved using modular fully porous-coated stem for revision total hip arthroplasty.

Adult↗